Inaugural Lecture Series: Interim Deputy Dean of the College of HSPC, Professor Stephen Wordsworth video transcript
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Professorial Inaugural Lecture Series: Patients, Protection and Pedagogy by Professor Stephen Wordsworth
[Paul] So, I’d like to next welcome my colleague the PBC dean of health psychology and social care, Dr Denise Baker who will make formal introductions for Stephens Lecture.
[Denise] Welcome colleagues, I'll just remember to turn my mic on so that you can hear me. Although that's not usually a problem I have, it must be said.
So, it gives me great pleasure to introduce Professor Stephen Wordsworth to you. Stephen originally qualified as an operating department practitioner (they were then called assistants) after finding himself volunteering in the hospital for a period of time.
He qualified in 1990 and then took up a post at Castle Hill hospital in East Yorkshire specializing in cardiothoracic surgery before diversifying into other specialities. He has been driven by a sense that he wanted to improve the care of patients in the operating theatre, and he started lecturing in a then nursing school on a part-time basis.
He then followed that with a full-time post at west Yorkshire College for Healthcare Studies before being transferred to the University of Huddersfield as part of the move of health professions into higher education. Stephen was subsequently appointed as a senior lecturer at Sheffield Hallam University while also carrying out the role of NBQ sensor manager. Ignited by the transformative potential of higher education, Stephen became involved in the development of the ODP profession in roles with the college of ODP's both as executive member and deputy chair of education and standards.
Stephen has gained extensive experience of professional and regulatory practice during which time he has authored several national policy and curriculum documents including the first ever higher education approved national curriculum. This led him to being involved in parliamentary lobbying and advising the NHS executive around ODP regulation. He was part of the team that set out the principles for the initial voluntary regulation of the profession in the NHS and the subsequent statutory regulation with the Health and Care Professionals Council in 2004.
His work within the field has led him to undertake various consultancy roles in the sector, including advisor to the Welsh assembly and most recently NHS Scotland in relation to the threshold level of qualification for ODP's there. He's also translated this experience internationally, providing masterclasses and workshops in a number of countries, most notably in the Middle East and Vietnam. His curriculum experience has also been applied to other aspirant professional groups such as paramedics and sonographers.
Stephen is currently a registered non-executive director of the health and care professions council and has provided national strategic oversight for various standards reviews across all of the 15 HCPC professions. And, until recently, had responsibility for educational strategy and compliance as chair of the education and training committee. He has held several leadership roles in higher education with portfolios as diverse as student experience, quality enhancement recruitment and internationalisation.
Recently, he has taken up the role of interim deputy dean in the college of health, psychology and social care. Stephen describes his career as a series of related but serendipitous accidents but promises that one day he's going to formulate a plan.
Ladies and gentlemen, it gives me great pleasure to introduce my friend and colleague Professor Stephen Wordsworth.
[Stephen] Thank you Denise for that very warm welcome and thank you colleagues, friends and family for joining in my inaugural lecture tonight.
It's a great pleasure to be here. Someone said to me "are you pleased that it's on campus and having it live?" and I reflected on that and promptly thought no. I probably would have preferred it to be online but here we are the adrenaline's kicking in and I’m glad I’ve done it! I’m looking forward to kind of... I guess what I’m trying to do is provide you with a bit of an introduction and a highlight of the career thus far. If this were a retrospective as an artist, people would consider that to be at the end of their career so I’m very much hoping that it's not. It's not that kind of retrospective.
What I want to do is kind of bring to life my personal and professional career in terms of various strands of activity and I think I’ve tried to kind of give the balance between some different aspects of my work thus far and hopefully you'll find that as interesting as I do.
So, there they are. There are three kinds of related but distinct and discrete aspects of some of the lectures that I want to provide you tonight, some reflections and some thoughts and some examples of where I’ve been able to get involved in some really (for me personally) very rewarding and exciting activities.
So, first of all it starts off with patient care and the sense that I guess I do get a little bit of serendipity working with patients in the operating theatre, the very same patients that are often at their most vulnerable, most nervous, most frightened, most scared of any time in their life. I get to spend time with patients, see things, hear things, look at things, talk about things that not even their closest relatives ever get to do. And that, for me, is a tremendous privilege.
But that's now allowed me to get involved in lots of other activities around Pedagogy and curriculum development obviously in the latter part of my career in terms of protection, but always coming back to that same core feature of how best to provide better and more patient-centred care.
So, we're just kind of thinking about that from the point of view of various strands and areas of my work so through clinical practice as an operating department practitioner, through my role in regulation and then in higher education, I’ve kind of tried to... they don't quite interweave but I keep coming back to those certain themes, certain dimensions and back to the related outputs in terms of policy research and curriculum that stem from some of those activities.
Someone said to me best thing too is to do a bit of ritual humiliation in the first place, so I thought I would do that. This is a kind of very personal journey and story for me, I would have never perhaps anticipated being here and having the privilege of doing this but nevertheless, I did. It's not a hard luck story by any means, I don't want to portray that but it probably wasn't the kind of trajectory that was probably first anticipated when I left school and started to do something else but I’m extremely proud of what I’ve been able to achieve but at the same time the help and support of the many people, too many to mention, have been able to get me to that particular point.
This is me in the sunny uplands, just coming out the barber's shop in Rotherham. Trust me, page boy was particularly kind of... I was going to say fashionable but probably not at the time. The second one is a really interesting... well for me it is. It's a really grainy image and I’m sorry I can't find a better one. But there I was kind of fresh faced, still needing a little bit of practice in the NHS, but really starting to kind of get a hook for teaching and learning. And that's probably the first conference that I ever went to support a group of students and I'll review a little bit more about that later on, and then obviously on to my doctoral studies that have been kind of used as part of a catalyst for some of the research activity that I’ve continued to do.
So, what I want to focus on first is a little bit of history really around this thing, this profession, this role and my involvement in it called Operating Department Practice. It's been described in a recent social media campaign as "the best career you've never heard of" and that's still the case. There are quite a few of us around, with between 13 and 14 thousand on the register working in hospital departments up and down the land, largely in the UK but there are a number abroad. But, if you ask anybody what you do it's really difficult to describe and people often prefer to say "well, I work in the theatre so I’m a sort of nurse but actually not it's a separate and discreet profession" and I’m kind of proud of that. We've learned a lot and come a long way from support with nurses and from medics and surgeons and I’m standing here today as an independent professional in our own rights. I think it's important to for me to recognise and celebrate that.
We're one of the 14 professions for the health professions family within the NHS in England and as of 2004 we took our place as one of the regulated professions within their health and care professions council. And as I go through this some of my work will probably demonstrate how I’ve been involved in some of those conversations and some of the activities to cement that practice.
Just to give some context to that, this is a quote if you like or a vision, statement from the sense of perioperative practice. It's a rather medicalised version in fact if you don't mind me saying, but it provides the context in which perioperative care exists within a broader continuum of care. So, it talks by being referred to as perioperative medicine sometimes; it's patient-centred, multidisciplinary and integrates medical care with patients and it's from the point of contemplation of surgery right through that continuum to full care.
So, if you were to look at the kind of various phases there is often... well they will be in that continuum of care, a kind of complete referral stage and at this stage you do your pre-assessment as well and that that can loop round again until the patient episode or the basic journeys is complete. But I’m particularly (but not exclusively) interested in this little zone in the middle that we call the intraoperative phase. And that's where much of my work and activity has centred as the ODP profession has developed into three very distinct areas.
So, the first one being in the anaesthetic phase of providing airway support to patients undergoing anaesthesia, not necessarily general anaesthesia, it could be local anaesthesia, regional as well as spinal anaesthesia as well. Pictures there of an anaesthetic room, for most people that's the last thing they probably see before they're going to an operation because at that point you'd be anaesthetised. Once you're through the other double doors as it were you'll be in our typical operating theatre there and in the middle would only be the people providing the kind of care needed, providing a sterile aseptic field.
We talked about the scrub role so that's where you're working with the surgical team in gloves and gown providing either care for the patient from the aseptic technique point of view or you also have roles involved in equipment and in invasive procedures as well.
And then the recovery phase, sometimes referred to as post anaesthetic where essentially, we try to wake you back up into a normal state of being as pain-free as possible. So, that's the location of that area of particular practice that the ODP role has developed into.
But it wasn't always like that and actually, if you like, the antecedents of the role are steeped in history, and I thought it would kind of... that's an oil on canvas painting from Warfield's eye hospital archive there and it talks about various different roles in the theatre, handlers, surgeon and box boys and beadles. And I'll read that out just so you can get a sense of it. "In those days since all eye operations had to be performed without anaesthetic, at least four or five assistants were to be employed to hold the patient down. The division's levels as follows: one assistant to fix the patient's head, one to depress the lower eyelid and fix the chin, and one to confine the arms and upper part of the body and one to secure the legs and lower part of the trunk." Essentially providing some kind of patient care in a very very limited sense. But nevertheless, the trajectory began.
So that's a really interesting kind of oil on canvas portrait and we know from records going back that these guys, these handlers and surgery men, the box boys and the beadles, there is a lineage to the modern role. I'll just read you a quote out from Edward Morris who wrote a history of London hospital, so this is... picture yourself, put yourself in the view of the patient.
"They developed standards before an operation to call all the assistants to hold down the patient. A bell's terrible clang could be heard by every shivering patient in the building, often a little child, a bell with a voice loud enough and harsh enough to wake up the whole of Whitechapel".
So, somebody in the back of that role there's ringing the bell to warn people that an operation was about to start, not to necessarily get people there to perform the operation but to watch, to do this, to sit in a theatre, to observe as a form of amusement. In between a cockfight might take place but the main event was often the surgery. The skill and the agility of the surgeon to perform the operations quickly ably assisted by the box boys and surgery men, etc.
So, I talk about this in a very... I guess informed sense that we genuinely are standing on the shoulders of giants and that includes lots of support from the medical profession as well. Just a couple of things to point out does anybody know who this person is? No? It's Mr Bumble, the beadle from Oliver Twist. He's a Beadle, he's an early ODP believe it or not. He, in his role would not only lock up and open the hospital in the evening and early morning, but he also went around with a brazier which was used to cauterize bleeding arteries. So, literally the fire was taken around the hospital, rather like a modern [inaudible] technique and the other guy in the middle, this interesting... sorry it's a really grainy image but it's the only one we've got, but it's Josiah Rampley and Rampley was employed as a beadle at Barts and that's what I'll come on to, it's a really kind of famous antecedent of the role.
The next one though is a really important chap called Fred Whedon and Fred Whedon was actually appointed as a box boy in the late 1930's still and ended up being the first co-chair of the operating department assistance professional body, ably supported by a number of important medics. So, a really interesting journey there to the point of initial qualifications that arose from some various reports, the Lewin report in 1970 and the Reverend report later on and interestingly both of these reports commented on the lack of staff working in the operating theatres. Sounds familiar doesn't it? Not enough staff.
So, on the shoulders of giants. Again, really briefly there the guy there is anybody else seen this? It's a chap called McGill. If you get into the trade McGill invented everything; forceps, tubes, restraints, techniques, all kinds of things, he really is the right upper echelon and worked for a little bit of time supporting surgeons that were involved in some of the early developments in plastic surgery funded by the Air Force in World War Two. But, the equipment there that you can see was made by McGill and his theatre attendant. In his history, in his memoirs he records that without these guys he couldn't have done what he did because they had to go away and make the stuff.
This is a Rampley just like Rampley there he is there. "Josiah Rampley's sponge holders". Doesn't sound very amazing, does it? But, let me tell you they're one of the most important and useful pieces of equipment that you can use in an operation. We use them for all kinds of things not least of all practically cleaning the patient's skin with the sponge holder but actually here you see two sponge holders have been really effectively used it looks to be like it's a hernia removal there. So, they're very much the antecedents if you like of the modern profession.
So, where do I come in? Well, after qualifying up in East Yorkshire, I spent quite a lot of time spending most of my development doing anaesthetics for some surgery, I’ve been around a number of hospital sites, I’ve worked in the independent sector as well as the NHS and there were a couple of things that started to emerge for me that at the time I was immensely concerned about, but at the same time rather privileged to be involved in so there were a couple of incidents that cropped up one of which we'll talk about in a little while, but I’d started to kind of formulate in my own mind "how could I best get involved? What could I give back to the to the patients and to the profession that I joined?". And one of the first things that struck me was this sense of patient care and the fact that when it worked really well it was fantastic and when it didn't the patients were a hinderence, they were an irrelevance sometimes, it was just another number on a list. And, that kind of worried me deeply. And I saw from that kind of thing some really bad clinical practice, there was some really poor practice that went on, not just ODP's but by and large from a group of people that have been recruited for all of the wrong reasons in my view and they've been educated in our system in a tradition that wasn't fit for modern surgery.
And what would happen is that in clinical practice, the standards would slip, something would be done about it and then there would be this kind of recidivism, they would just go back and do the same old stuff. Sometimes it could get them in trouble, and they would just be moved on to the next hospital, no form of regulation, no form of accountability for their practice and that worried me deeply.
It's centred on the fact that for me the qualification just wasn't right. We were still operating through various vocational models of education, by in large the gift of the anaesthetist or the surgeon that would signs of forms of competence. Learning by wrote, not being critical, not inquiring and not reflecting on practice and your role in that practice development. So, I would often see poor team working, professional hierarchies that were not effective that were actually getting in the way of patient care and were there deliberately to keep the regime as it was, and that for me again was very worrying.
Perhaps one of the other major concerns at the time was this sense that ODP's (we were called assistants at that time) were completely unregulated. Their only accountability really was to their employer, to the precarious liability of an employer. So, you were literally there under the authority of your employee or employer and if anything went wrong, they could either choose to kind of cover it up, move you on or sack you. But that was it, it stopped there, and the practice didn't it just got moved on and moved on. And, within that there were quite a lot of... well there's some criminal activity, there were people in that job, in that role, in that very privileged position that shouldn't have been there, and they were abusing their position of trust. They were abusing their position of trust sometimes with patients, rarely but particularly in terms of misuse of drugs and medicines.
These are a very small minority; I’m not talking about this kind of you know systemic problem here but nevertheless it was and there was this lack of accountability that came with all of that. And, I kind of resolved at that point that, you know, my best influence, the best I could do was to get involved in how things might change and I’m just going to again, for the sake of brevity I'll read case study out here that at that point where I was formulating these concerns and how best to move my career, this happened, and we'll come back to that as we go on (it's a bit of a case study) but a left in-growing toenail (we often on the list used to refer to people by their operation, not by their name, we'd not asked them who they were what their concerns were, we didn't worry about that it was about getting the job done).
So, a patient was scheduled for surgery at the end of the list, but a decision was taken to alter the order of the day. At some point two patients were sent for simultaneously; the first patient was anesthetised as planned and went into the theatre. The second patient went directly into the aesthetic room. An ODP was called from a different theatre to scrub and in the anaesthetic room the surgeon had begun to administer the local anaesthetic into the patient's right toe and the surgical scrub that was in situ, the foot had been partially covered and was draped and being cleaned prior to the operation. When asked to confirm which leg we were going to operate on, the patient lifted their right leg at which point the surgeon made the first incision. So, we should have been operating on the left side and despite asking the patient, we we're operating on the right side. That ODP was me. That was me that day that made that mistake because I didn't spot it, I didn't shout up, I let it happen and we were in a situation where a whole series of factors is completely and utterly wrong.
If you design something to go wrong that's the example there. And that had a profound effect on me, it was... people said, "it's just a toenail, really?”. That could have been anything couldn't it? And you know, that really did have a lasting impact on how I would go about then in terms of my career and my future efforts to stop that from happening again wherever possible. I'll come back to that.
Was that an isolated incident? No, it wasn't. It was pretty isolated in the operating theatre I worked at, I have seen other examples but if you build up a picture of that kind of activity going on across the country, nationally, worldwide, it becomes a bit of an issue, a big issue to be perfectly honest. And there was and still is to some degree a failure of the existing safety culture. Typically, it's the example I gave there of left or right wrong side surgery operating on the wrong limb; sometimes when we turn the patient over prone it's easy to forget which is left and right, your left or my left? But it happens. The surgeon at that point decides that he's going to stand on those wrong side of the table from where he normally does, he or she. All sorts of things can start a snowball effect of problems. And one of the real original problems with when things go wrong, was this idea of the wrong prosthesis, so putting in the wrong thing, wrong size usually, not for the right patient and could be the wrong side as well. And one other thing that came from the initial work on looking at safety culture which was added later (nearly original to the other one), but the other one that was added later was this sense of retained foreign objects. There are examples there of the wrong hip... and there are some artery forceps that have been left in the chest cavity there as well.
So, they're examples but there are others, one of them being safe anaesthesia so the maintenance of the patient's airway; it could be because of a dislodged tube or a blockage, equipment, mal administration that kind of thing. Or it could be through surgical infection. And the reason behind that problem with surgical infection is that for years and years now we've had a regime about prophylactic antibiotic treatments and regimes. If given at the right time, approximately an hour before surgery in the right dosage to the right patient you can almost guarantee (unless there has been a catastrophic failure in the operating theatre), decent prophylaxis from infection but that's the problem. We still can't guarantee that those protocols happen when they should despite all of the evidence.
And finally, that sense of surgical team working not being at its optimum. How to optimize a culture that is deliberately designed not for people to maybe fuss, not to declare a concern, but to get on with it for the sake of the patient and to understand that to work differently, sometimes cutting the corners would mean that we would be more productive. People don't make these decisions to provide bad patient care, but there's a kind of sense that in starting a conversation about "should we bring another patient in when the other one is still being operated on?" (By the way is completely against all protocol) but it still happens. Even if done with the best of intentions.
And finally, about the surgical teamworking stuff this sense of situational awareness; setting the theatre up right, providing optimum equipment usage, optimum safety standards, having the right kind of ergonomic design, understanding the flow of the patients better together through the operative field. And so, that's where I started to learn and understand some of the theory and some of the current work surrounding those activities and got involved in developing work around safe surgery.
The beginnings of this are a simple really; from the 70s, largely in the US there'd been a growing, I guess, almost evangelical movement among some particular surgeons to become the best in the world, to reduce the risk to patients and to actually use that as a method (the American healthcare system is set up differently to ours) as a method, as a means of saying "we are the best because we're the safest, not because we're the quickest". A completely kind of different mindset in that sense. And so, there's some kind of early messages from the 70s and 80s that were picked up by the World Health Organization that's culminated in a number of developments. And it's become an essential kind of global healthcare. And actually, what we recognise now is that when things go wrong surgically, in the perioperative environment, it's becoming quite a global health issue. In fact, it's a public health issue because of the scale and size of things when they go wrong.
Surgical interventions account for about 13% of the world's total what's called Daily Disability Adjusted Life Years. 13% of who went into the operation to get better, 13% of them come out worse at some point, still a lot. We haven't actually got any real data on how many operations were taking place let alone how effective they were. And mortality rate, look at the kind of difference there between 0.5% and 5%, couldn't even pin that down any further. And complications, up to 25% of all patients experiencing some kind of surgical complication. Half of everything that went on in the industrialized countries where there were adverse effects stemmed from surgical intervention and half of the cases where actual harm was also originated and had their origins in surgical intervention. And that's in what's considered to be the industrialised countries, in the developing world the statistics are stark, if not worse in some parts of the world but not all, it isn't a simple picture of that and there are some reasons why.
In sub-Saharan Africa at the time when we were developing World Health Organisation initial surgical policies you were 150 times more likely to experience a surgical intervention, particularly an aesthetic intervention. So safe surgery (in that sense) stems from some very simple tactics that have started to be deployed by the World Health Organisation, including a checklist which sounds obvious and including some alerts that meant that every time something went wrong we could record it, report it, learn from it and that actually would develop particular standards that were able to be used that went beyond the checklist which was very generic that could be applied to every different surgical field in every different hospital.
So, that is the original surgical checklist that was developed by the World health Organisation (WHO), it actually talks about nursing there because it wasn't developed particularly from the UK perspective but nevertheless that is the original checklist. And by in large, continues to be used successfully in most jurisdictions, most countries and across all continents. It's a very simple checklist. It's not rocket science as they would say, but it was designed deliberately to send people through a protocol, through a series of actions and activities designed to interrupt in a sense.
One thing that came from that was a national safety standard for invasive procedures and I was invited to take part as part of the patient safety expert group back in 2015 and my contribution there was from the non-medical side, and it involved a series of workshop related activities and case studies that we developed to provide insight into what went wrong (similar to the toenail that I talked about previously). And the reference group that I was working with particularly exercised with designing interventions that were deliberately not just about the medical team deciding when things had gone wrong. It was a multi-professional, multi-layered approach to reducing risk. It was incorporated within the NHS as an NHS widely executive decision and it built on the principles of checklists, and it acted as a catalyst for something called LocSSIp's (they just mean local standards) so in other words, you could take the general checklist which is usually designed for orthopaedic or general surgical use and apply it to simple cases or very complex cardiothoracic situations; orthopaedics gynaecology anything you like and particularly around invasive robotic surgery.
So, that was a really important development which it still is today you know. My involvement in that has been a source of actually a catalyst for even further work that I’ve been involved in and actually it’s started to bring home that there was now a different way of providing a culture that was designed to be multi-professional, inclusive and action focused rather than trying to hide these events that went wrong.
And it's led to a couple of activities that again, I think are probably worth pointing out and if I could, these are some theatre safety workshops and checklist master classes that I ran in Vietnam. I was invited there by a call out from their Health Ministry and responding where I was working to that call to try and provide some fairly, I guess engaged, but interventional aspects of using the checklist. Trying to get surgical teams (largely in various hospitals in Hanoi) where they'd identified a real problem and to kind of understand how we could use the checklist and how we could empower surgical teams to start to have a more patient-focused attitude and example to their work.
The top picture there, (you probably can't see but there's a second one there). See what's happening there? It's a baby, it's a c-section, caesarean section and that's at the point of obviously delivery there. The reason why I was in there was because there had been a higher incidence of surgical sepsis infection and medical and surgical error, postoperatively in gynaecology and in our surgery in that particular hospital.
This one is in a separate hospital across town, still in Hanoi, and this is a robot working on really small neonatal children with cardiac heart defects. Almost no incidents of patient safety going wrong. Purely and simply because they had taken the principles of the checklist and designed something very simple to go along with this complex intervention, whereas what was considered to be fairly standard stuff was allowing mistakes to take place.
And the other one - similar one here where we're doing, I think they're doing some laparoscopic work there. So that was a really interesting piece of work that I got involved in and likewise similarly in Kuwait, looking at some, I guess similar skills, but here looking at what we started to describe as some non-technical activities so I was particularly interested in how we were able to help their theatre teams (largely in private sector but not exclusively at private sector hospitals) to get to understand a better culture, team working in its essence really which has been identified again through the ministry of education as not being where it should be.
Healthcare in the middle east is different, well the resources are immense. You know, you walk into an operating theatre there and it really is all bells and whistles. There's nothing that you couldn't want for. But there are some very different and unique challenges that's going on there, not least of all cultural, that's just one of many, but a real difference in hierarchy and cultures that almost seeming to collide in the operating theatre rather than coming together. That was a source of concern and poor practices in certain areas. And so, I was able to kind of go in and work with them in terms of some of those communication, team working, technical skills - what we would call "things that should never happen". "But it should never happen" is what often gets said and that "but it should never happen”, really, we're talking about something called "never events" is a better way of describing them. So "never events" are those kinds of things literally that should never happen but do. They're the kind of things that happen and they've happened before and been repeated, it's not the one-off thing. It can’t be a one-off thing for it to be a “never event”. It has to have a history and a pattern to be recorded. They're serious incidents are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level. That's the definition that the NHSI operates within the NHS in England, so we're talking about something that is wholly avoidable and has been seen before and we've put interventions in place to try and stop it.
It's term again stems out of the us in the 70s, particularly a chap called Ken Kiezer who was a surgeon originally (I believe) but was working in a patient safety role and he started to kind of formulate a sense that these things were happening on a routine and regular basis, but everybody kept saying "well it should never happen", but they did.
Okay, this is the latest set of data from the UK, particularly from NHS England. It's collected on a quarterly basis and it's now a statutory requirement for all hospitals to report this kind of stuff in. It may be a little bit difficult for you to see but I can point out some of the key features there. It's essentially an amalgam of all the data from potentially 223 different NHS trust sites and 3282 operating theatres across that English landscape, so the data is still very clear. If you look at the grey line, this one here, we're talking about what's considered to be retained for an object's post procedure, so the number is hovering around 100 in that period of data collection. You might say "a hundred over what?", eight years or so? It's still quite a lot. The rest is self-explanatory; wrong site surgeries I’ve described, going still on a little trajectory and actually, just about plateauing in terms of putting the wrong prosthesis in. So, these kinds of things are still happening despite all the patient safety activities that have gone on before. I’ve just had a ten-minute warning so I’m just going to flick through a few.
So, early work was really about looking at where have these "never events" happened before. The Clinical Human Factors Group started to define activities which was set up by a chap called Martin Bromley, whose wife died during anaesthesia. It's a very personal account of what went wrong that has provided a catalyst for the Human Factors Group to look at what we can learn from other industries, and these are some of the patient safety critical industries that we have done. And it's really about the power of persuasion; has anybody come across that? That's a gentleman's urinal. That that isn't a fly on the porcelain, it's painted on deliberately. I'll leave you to guess why, but what we're trying to do here is change people's behaviours (I won’t dwell on that one) and to think about how we might do that from those other industries and it's quite obvious if you look at some of the... this is a kind of a briefing set from the airline industry brief, pre-take-off checks, take off crews, landing et cetera et cetera. You can kind of see where they're coming from. Again, it makes some pretty obvious sense of why we might learn from others in this sector.
And you've got this idea of human factors, the things that we do, that we find a way as human beings of working around. There's a lot of science (and some of my psychology colleagues will understand this even in even more depth) but they then combine with those kinds of non-technical skills; communication, leadership that kind of thing and at the centre of that kind of chaos you find those “never events” that take place. They're different shapes and sizes and that's what makes it, if you like, lead to a series of events that shouldn't happen.
Possibly you might have come across like this kind of early theory, a Swiss cheese model. This is a reasons model coming out of important work that colleagues did around patient safety, and basically what it says is that you've got two pieces of cheese at the end with holes in them and if the holes line up, then that's when you get problems. It's when everything comes together almost to cause “never event”. You couldn't plan for it, but it happens. But in the middle, if you stick the checklist in, it will act as a gatekeeper, it will act as a filter, as a mechanism for trying to reduce that number of incidents that could (if the stars align) all go very wrong.
I’m just going to flick to that one there, the scenario that I gave, as interesting as it was, was real and it still affects me now. I can't imagine that I would have allowed that to happen, but I did. The equipment was put in place for me, we were operating in a different theatre. It was a rush, nobody told me that they had turned the patient. The surgeon had started to get on with it; the patient had been prepped; we didn't organise ourselves; the environment was wrong; we didn't even get in an anaesthetic room. We weren't in the proper operating theatre. Jobs and protocols hadn't been aligned; we hadn't discussed it; it was a perfect storm. If I were doing this now, as I talk to students about this in some of the research that I’ve done with students particularly, it's that kind of system issue that we work through to try and find a resolution and understand what went wrong.
I'll give you an example of the equipment. One of the things that often goes wrong. Three seemingly similar syringes, all 10 mil syringes, what's the problem? Any ideas? Well first, this is a normal 10ml syringe yeah? "Grab me a 10ml syringe please. Quickly!", and you go and grab a syringe, draw up the drugs, put the saline in and give it to the patient. Except, all of a sudden, somebody's ordered some 12ml syringes. People just fill it up. They don't look at the number 12 and they just fill it to the fill line. "Here, have this it's 12ml, oh that’s adrenaline", you’ll double your dose. You get the idea. And this one here doesn't have any markings on at all! It's just guessed work. It’s just for flushing saline through a line. Can you see how the equipment there in the wrong situation, in the wrong hands is a recipe for disaster?
I did a little research project that kind of stepped out into a thing called "ODP's in the fast lane". A catchy title that basically said, “we're going to use some of these Human Factors training on students”. And you can imagine you know; this is a pit stop challenge. There's the pit stop, there's the crew; there are some similarities to the way that the operating theatre is laid out. Being in position, knowing where to be; left, right top, bottom. Understanding your moves, your tactics, the communication between that. Again, these people practice it, ad nauseam. We didn't. It was just kind of accepted that you would get to learn some of that. You would understand how this works almost the same as when I was training, and that's what kind of set me about doing something about it. And so, that's the publication it came from. That little bit of research there. Essentially, we were learning from those demands upon safety critical industries to think about timeouts, debriefings, communication, teamwork, understanding each other's roles, reducing hierarchy, working multi-disciplinarily.
And that then, with all of those incidents, I started to think about how is that best applied? Where do I take that kind of stuff? Where best do we make sense of all of this? And actually, through a series of curriculum activities, where I’ve acted as either co-investigator or as principal investigator, has led me to some really important development work. I’ve put one up there for Chris; Chris was a colleague of mine that taught me a lot about working in higher education. Sadly, he's no longer with us but I kind of feel like I owe it to him to tell that tonight for some reason and so I feel it's important to recognise that our journey (that we started to take in terms of curriculum development) is still ongoing and it's still really about affecting patient care.
One that I would just signal as being important for me personally was a research project that I ended up doing on behalf of the professional body, looking at an investigation through the curriculum model. It was in the day, back in 2001 a diploma, but we were looking to try and change that kind of learning style to create that reflective understanding of what a practitioner should be like, where they would open, reflective and challenging to provide a level of care that had not been there. And so, we coined the phrase... or I coined the phrase in there which was "practitioner". Again, not rocket scientists, but we were fundamentally reflecting the difference in the way that we were educating the future students. And that type of operating department practitioner stuck, and it's called that because I put it in there and it got picked up by the regulators, by the NHS, by policy bodies, curriculum writers etc. And now, it's a protected title and I think it was probably worth doing in the end. Not the kind of most amazing curriculum in the world, looking back it was a pretty standard higher educational affair but nevertheless quite important.
Some of the theory that was around that (I’m sure people will be familiar with), but we were obviously trying to bring forward those ideas of theory and practice learning, student-centred, patient-centred and for the first time recognizing the role of evidence-based and problem-based learning and research.
I’ve also shared various stages of being part of other groups that have been curriculum derived, often with research elements and I’ve put some examples, right through this sense of developing curriculum as the professions have developed, to this idea of scope and practice and to start to define legally what it is an ODP can do, can't do, or should be able to do it. And so that work is still ongoing.
So, what I want to do is kind of think a little bit there about coming on to the idea of research and about how that's been then implemented in various other activities and one of them was this piece of work about defining what it is that the profession does. What is a profession? Everybody has a view and an opinion, and at the time when I was starting to look at this (and this is coming through some fairly recent work) the prevailing and accepted norm was that we're talking about honoured servants of public need. "Conceiving those occupations especially distinguished by their orientation to serving the needs of public through the schooled application of their unusual (or controversial), esoteric knowledge and complex skills." I kind of agree with all of that but why does it have to be esoteric? Why does working with patients in a healthcare setting, be a doctor or a nurse or another thing, why does it have this element of magic about it? Why can't we service that and define what we really mean by that? And that is what I’ve done in some other interesting work that has stemmed from activities around trying to define, from working with professionals, their view of who they are and what they do, what makes them different or not different, as a result of having this title of practitioner. And just think, building on the work of people like Diane Reyes who talked about a new set of professions, a professional that's not necessarily esoteric or coming from a very specific background. New occupations and blurred roles and democratisation, knowledge and skills.
Okay, I do want to just kind of hold on to some of this little theory and I do realise that we might be running out of time. I got involved as part of my doctoral level work, from a sociological point of view of trying to understand that team working, how things work in the operating theatre. Why do some people behave the way they do? Why do you work with others and not all of them? Why do students choose the careers that they choose? Why do the decisions we make differ from one day to the next? How can we make sense of all of that?
And so, I started to look at some theory (sociologically based) and I had a real epiphany moment with this with chap called Pierre Blodger, a French sociologist. He was a bit of an outsider looking in but nevertheless, he reached significant academic heights in the grander call in France from a starting point, whose untraditional let's say. I’m not for one minute making any parallels with the great man himself, but he writes about techniques and tools to describe how that kind of hierarchy or social class can work. Not in a pejorative sense but just to say, to explain it. It doesn't come at you from some kind of Marxist perspective about how some people are high up and some people are not. It's just as it is. This is it and understanding what it is. And he talks about the field, field being a kind of science or complexity, we could be in an operating theatre as a field, higher education is a field and a discourse and a discipline. Sometimes we're in a personal field in our own lives, our work lives are different and occasionally those fields collide.
From the original French, a field is a scene, or a site of combat isn't a flat playing field or a football field that I use the analogy of, it's more of a kind of, you know, a bit of a warzone. But, within that context you get to see how people position themselves differently, they take roles within the field, they'll legitimise their practice and the way they do things through this concept of field and their legitimacy comes from this idea of capital (people may be familiar with that) which is a more commonly used term.
Our job asks us to be careful about just using capital on its own because it is in and of itself, on the same part of the coin. Capital is the other side of habitus. It's the kind of way that capital, owning expertise or knowledge or connections or people or activities or a sense of distinction that comes from your particular use of capital, is actually then embodied in the habitus - the way we are, the way we do things. And all this suddenly makes sense when you're in an operating theatre. You've got people doing some very complex stuff together in a team. But operating (literally) on a very different kind of capital, a different field, a different set of distinctions in their knowledge and experience and in their world view, the way they perceive the world.
So, I’ve used that one to try and understand, to move forward in understanding not only how curriculums develop, but how higher education models develop and how in some sense, higher education is both transformative and at the same time perpetuates the same kind of field of discipline and discourse and hierarchy that the module describes it can do. Nevertheless, interesting work and stuff I’ve continued to use in my kind of academic thinking and discourse to this day.
But what that led to was this sense of the genealogy of profession. Understanding that, meant that I was understanding how to legitimise professionalism, to decodify it, to demystify it, to explain it, to understand it a little bit and actually (going back to another French theorist), it's Foucault that describes that sense of genealogy - when something becomes almost legitimized often through the state or through a kind of collective consciousness within the public's mind; within a sense of "this is acceptable, and this isn't". And that genealogy really developed for the ODP profession once we got to the point where statutory regulation for our group of practitioners was recognised. We were at the point of genealogy and legitimized through the sense that we were considered their professional, on the register, subject to statutory regulation and therefore there was a sense that the state could intervene in what was happening, what worked well and what didn't, that kind of discipline.
Some activities that I got involved in (I think we've described). I’ve done some position statement work and some regulation crafting for the BH. Helen Jones is a really important figure in our story. She's the MP from Warrington north and had a private members bill and stood up and told parliament how great we were, and people listened to her. So, we get into this situation where we're in the health and professions council, statutory regulation at the highest level and invasive to the degree that they can end your career, but at the same time operating in a sense of a personal private model where as long as they require you to maintain standards, they don't necessarily pry into your ability to do that unless something goes wrong.
So, the point of that is to safeguard health and wellbeing of persons using our service of registrants. There are 15 regulated professions at the moment. There were 16 but we were really careless and lost the social workers. They've declared UDI and gone out on their own. But the same principle that looks at regulating doctors and nurses is applicable to the Health Professions Council.
Accountable to standards, there are four sets of standards: three of them apply to the individual and the fourth one, education training, applies to the university of Derby (one we often operate as part of practitioner programs, diagnostic community programs et cetera et cetera).
My role has involved quite a number of different research activities and they've come through various standards reviews. So, when we were about to draft or rewrite standards to make them contemporary and current, there's always a professional liaison group that in effect does the work of the research committee to find out latest practice; to understand opinions and trends; to look at the evidence and to look at the details of where practice standards are sitting, and I’ve had the privilege to be involved in a number of those and it defies the research strategy. It ended last year (because COVID got in the way a little bit) and we're now at the cusp of obviously developing the research strategy. But I’m incredibly proud of the fact that we were going from a very data-rich organization but doing nothing with it, research poor but information rich, data poor, that sort of thing. I think it's a very different place now and I know I’m kind of running out of time, but I will just give a couple of examples of how we got to this.
This was a study that we conducted a little while ago about fitness practice. Again, trying to identify when things go wrong. And what we could see there over a period of time (with 76 operating department practitioners referred to fitness for practice cases by in large) you know that referral is tiny compared to those of the rest of the register but the nevertheless, if that was 76 individual incidents where the patient's care has been compromised, it becomes important. Every single one of those cases. And what do we find? The same stuff that was happening when I first started working in the operating theatre. So, I’m thinking, "am I going to tell them this? That my life's work has not really got us very far?" I’m just simply reflecting these are complex problems. We've come a long way but there's more to be done.
It's still talking about dishonesty, stealing drugs, forging records. It still happens. Lots of, if you like, boundary issues where there is a distinction that some practitioners can't make between home and life and work. You're never off duty. You're just not. You can't behave in certain ways in public if you are on the register. They're not compatible. So, very few of these, the point I’m getting to is, very few of these are centred around competence. They're largely around conduct, professional attitudes and values that we can see emerging in some of those patient safety incidents throughout some of the previous activities of research.
A final piece of work that I think is really important, was looking at why (this is looking at paramedics and social workers), why would we get proportionally more referrals from those professions than the rest of them? Even though they weren't the largest number on the register. So, there's a research study put forward that we did that was carried out and was responsible for bringing that back to the education training committee, and ultimately to the council to understand what was going on. And a disproportionate number of referrals that just didn't actually get to further investigation. It was just not easy in the system; we didn't quite understand what was going on. One off incidents, the kind of things that were low level and nevertheless the patient had reported it, the employer had reported it, sometimes the practitioner themselves reported it.
Clear cut distinctions should be made between the nature of the case considering that each stage of the investigation process is considered. You couldn't say "this factor would result in them being dismissed and this factor will mean it will go all the way to them being struck off the register". It was none of those kinds of correlations that emerged from that initial system of data. And lots of complexity and challenging practice but not necessarily something that you could identify was coming from all of the professions .it seemed to be about the maturity and the distinction of these two newer professions. And what resulted from that piece of research is this, which has been used elsewhere. We didn't invent this kind of scorecard, but it gives a kind of indication of where we see the continuum now of fitness to practice, so it is basically that sense of, you know, theres some stuff such as traffic offences, personal dispute boundaries, some off-duty incidents that might be indicative of something else but in and of themselves doesn’t mean you're going to get struck off and it doesn't mean that the patient's been harmed but there's something there. And then there are one-off in the dark yellow which is kind of an escalation of behaviours that are not acceptable, that transgress those boundaries, that raise concerns. And then there are the outright criminal activities in the red you know, there will be a criminal investigation that always precedes the investigation by the regulator, which makes the process much more streamline. But it's in that centre bit which is where we've been trying to get to. How do we use the research or the data that we've got to then try and put interventions to regulate in a different way? (And I promise you; I am nearly there).
So, the key recommendations that come from that is that engagement and early resolution helps. In some sense, as a result of this research, we've even tried to look at the story to do justice models; so, the patient/service user can meet with their practitioner, very few take that option but there is a sense that that in some instances might work. This idea of candour. Some people just want someone to say, "I’m sorry" and sometimes that's powerful enough to make it go away. But we often don't do that. We'd rather fight it in the courts than say I’m sorry. Registrants and how we might think about registers in public, signposting to appropriate methods of resolution and how we can work with professional bodies. But most importantly, of all educators and universities to get these messages engraved, all the way back into those curriculums that I’ve had such privilege of being involved in, the work has been done. How does that look in the system's regularities? Is there something going on? For example, what happened with North Staffordshire? Did we need to talk to CQC about something more systemic? Were they just individual isolated incidents, or were people behaving to a norm that they should expect it to be?
This publication here, again has kind of set the scene and stemmed the start of the conversation for the next round of regulation reform in the HCPC. For many years now, the Government have talked about are reducing the number of regulators. It's a very crowded space in the UK with 12 of them doing essentially the same thing. I can't see the GMC disappearing. I can't see the NMC disappearing, but there are lots of others that might, and I sincerely hope that it won't be the HCPC. I feel that understanding the regulation through the lens of the research and the data is a really important reason why that model, multi-professional motivation, all of those professions working to the same generic standards is really important and it's actually that's what makes the distinction.
So, where has this work and research taken us to? Well, there's right touch regulation. It doesn't have to all be heavy handed, you don't have to strike everybody off, it is okay to say "no case" to some people, it is okay to say sorry and then it might go away. Upstream intervention, getting at the practitioners in the future (students in particular), getting them to understand how these things, these small problems, preventing small problems from becoming big, doing something about it with them and the employers. Focus on prevention, data versus intelligence and regulation is part of a broader system, understanding the context in which regulation healthcare practitioners exists within the field in a different discourse of the employment of hospitals, in terms of public discourse, in terms of social care. All those different activities that create this ecosystem of regulation, with more and more and more qualitative research, in particular, to understand what the patient felt, what happened? What was it like for them?
And finally, my wife is in front of me, we don't get out very much. But, on that slide, little did I know all these years later, there she is! Here I am! So, I just want to say a big thank you to her for being on this journey with me. She's an ODP, still practising, still telling me about the stuff, still keeping me ignited, grounded, centred and to come across that was really nice. Without her help and support and all of my family and colleagues I wouldn't have got to where I am. So, I do thank you and apologies for running on.
[Paul] Thank you very much indeed Stephen. That actually personally resonated quite well with me because I'm the son of a surgeon.
Any questions? Any questions?
[Audience Member] Where next for Operating Department Practioners, Stephen?
[Stephen] Okay, the next thing is I’m involved in is a national consultation on prescribing, so the ability for ODP's to give drugs under certain conditions. There are legal mechanisms that allow them to give drugs/medications right now but it's very complicated and torturous. And it means it interrupts the patient care pathway because you've got to say "oh! Do you mind signing this?", when actually the patient needs the drugs when they need the drugs. So, that's a really important piece of work but that operates at a glacial pace you know? The ice caps will melt before the legislation probably gets there, but it is ticking along a little bit. You're fighting the medicines regulation, all kinds of stuff but it is an important development. And I think morally it just needs to happen. The other thing I would say is the sense and profession, COVID has shone a lens and a light on the profession that probably hasn't been there before. And many of us including people in this room were deployed to go to intensive care units, providing intensive therapy to ventilate patients. One of the things that's always been quite strong in the bucket of skill sets has been airway management. So, if you can manage the airway here, you can do it anywhere and I think there's been a recognition that some of that skillset (in the current climate of the NHS) could be used elsewhere. So, that may be advanced practice.
[Kathryn Mitchell] So, last week when we had all of our graduations, one thing that our trustees said was that the best thing that people had done was ODP.
[Kathryn Mitchell] Do we have enough of them? [Inaudible] The bit for me is that in the sense they still saw huge opportunities through the skills of ODP as a much more usable part of the workforce.
[Stephen] That's great to hear your comments. The answer is that there aren't enough ODP's nationally. Complex reasons why, but by large, there's something to be done about selling the profession isn't there? It's a bit behind closed doors, in fact it IS behind closed doors and you've got to venture in either because you're a bit odd or you need some operation, and none of us want to really volunteer for that very often. So, there is a hearts and minds piece to be won Kath, but having said all of that, I think that we can attract many more than we do. There needs to be an unblockage of the system. That conversation that's happening at the chief exec level needs to filter down into commissioners within the trusts and I think they are, no criticism, but their management structures within the operating theatres have not really caught up with the workforce. We could do all of those and I have to say, part of why I came to Derby was because of the involvement in conversation people like Denise. We've worked together on other things before, and I’ve always wanted to try and find new solutions and Derby was thinking about doing things differently. A couple years ago you know, why couldn't we do the ODP program? All of those technical/non-technical skills, but online? And we can, we have. Through an apprenticeship model we could fast track it. You could have master's routes, it's endless. We kind of need a mandate to allow that to get past those early discussions about viability because otherwise we're talking about niche products, and we shouldn't be. This demographic we're in now, the numbers of people waiting for operations, is at a whole all-time high. It's higher than when Thatcher went into government and there was a whole series of activities there in the Thatcher admin to transform the NHS, to provide more operating time, to demystify some of the regulations around that. I mean, by large, we got there. But now we're way back. Waiting lists will be a public health issue, people will sadly get worse but there's things we can do about it.
[Audience Member] Just in the online space obviously but I’m really interested in how you could develop the interprofessional, multi-professional in the institution here. Might come from [Inaudible] I think there is real potential there about what you were just saying.
[Stephen] I would agree. And actually, I’m at that point in my career where we've come full circle. I would go into the operating theatre when I was first training and it would be, there could be conflict, there were hierarchies, there were traditional laws and responsibilities between ODA's, ODP's and nurses. By and large, that's a conversation we've all won. What's next is how do we then work flexibly to provide some of those answers to those workforce problems we've got now? And, it might not be about traditional boundaries, might it? If another colleague were here today, he'd be asking "What about acute care and ICU?". Why can't we have that practitioner that has a bit of all of that? We're having conversations about what we do in terms of the rehabilitation space, why does it have to be in physiotherapy or an OT in that traditional model? Why can't there be a hybrid skill set that translates all of those different professions? There's nothing. The University of Derby wouldn't stop us because we innovate like that. Yes! But we would want to innovate like that. We would, we want to explore that. We are the game changers, but we need to convince others there is merit in doing that and being bold enough to do it.
[Audience member] Listening to the last part of your presentation, you were proposing a consultation of the multiple [Inaudible] Are we not risking going back to that issue? [Inaudible]
[Stephen] What I would say is that in the UK, for far too long, even though we, for example nurses and ODP's and the other 16 odd professions, they're in a different regulatory body but the legislation, the health act and the principles are exactly the same. So, the NMC chooses to set up its standards and it's all in as a council one way and the HCPC in the other. They should, in my opinion, be more synergy about that. The way we deal with a practice case for a nurse, or a medic should be the same in my opinion, so there's some synergy there that's required, I think. Likewise, for far too long, the NMC could strike a nurse off and that nurse could be a duly qualified ODP, and they'd not tell us, and vice versa. So, there is that kind of thing, that collaboration within that field you know. Thinking about that competency field that needs to happen. But, where I would share in that view is, for example in the UK, there is a model of the Physicians' associate, Physician's assistant that has emerged from the US. I think it was a mistake to regulate them with the GMC because I think it potentially means that they are almost going back to the handmaiden of the surgeon. I know they're not [Inaudible] but my point is that I think there needs to be a different regulatory space there. But the issue is that as we move into this point of diversification, of those boundaries and they're blurring some of those professional roles, you can't regulate everything, and you shouldn't need to, should you? Do you tie everything down in regulation? I think that if you do you probably won't get the innovation that you need sometimes.
[Paul] Thank you Stephen, I’d like to hand over to give you a formal vote of thanks.
[Denise] Stephen, thank you so much for a very informative lecture. I think my reflection is that we started off about hearing your professional journey and how almost by accident you ended up being incredibly influential in that profession. What struck me is that the patient has always been at the heart of what you wanted to do, whether it is working practically in the operating theatre or through your regulatory function and the educational function and experience that you've had. And you've truly informed the curriculum based on research and been a significant player in the field. I would just say that I’m not sure whether we should have been warned more about the pictures of operations or that haircut! That will stay with me for a long time! Please colleagues, join me in thanking professor Stephen Wordsworth for a very enjoyable evening.
The screen fades and a blue screen is presented with the University of Derby’s 3 hills logo in the middle of the screen, in white.
Inaugural Lecture Series: Interim Deputy Dean of the College of HSPC, Professor Stephen Wordsworth video